Should you go upside-down if you have glaucoma?

Inverted poses are important in Iyengar yoga. Senior practitioners often cite an inversion as their most essential pose. (Sarvangasana (shoulderstand) seems to be a favorite.) Can anyone do inversions? General contraindications include spinal disorders, hypertension, and glaucoma. Recently, however, I’ve met yoga students with glaucoma who do brief inversions with the approval of their ophthalmologists. Hmm…

Around the same time, I read a PLOS ONE study published in December 2015 that measured intraocular pressure (IOP) in 10 subjects with primary open-angle glaucoma and 10 normal subjects during the following poses, each done for two minutes: Adho Mukha Svanasana, Uttanasana, Halasana, Viparita Karani. The researchers opted not to study Sirsasana (headstand) to see if less-inverted poses also affect IOP.

In both normal and glaucoma subjects, the following occurred:

IOP increased in all non-upright body positions. Pressures increased within one or two minutes after entering a pose. Likewise they returned to baseline values a few minutes after exiting the pose. (The prompt “return to baseline” is apparently one reason why ophthalmologists allow glaucoma patients to do inversions.)

IOP change is directly related to body angle from upright to inverted.

Among the four study poses, Adho Mukha Svanasana caused the greatest increase, followed by Uttanasana, Halasana, and Viparita Karani.

IOP remains elevated while non-upright position is maintained.

Glaucoma subjects did not show more severe IOP increases than normal subjects. Both groups showed a rise in IOP between 6-11 mmHg.

Note: Limitations of this study include small sample size, short pose duration, no measurement of blood pressure, and age variation between glaucoma and normal groups.

What the study could not (and did not) answer: Are temporary IOP increases safe for glaucoma patients?

I solicited my own eye doc’s opinion, and he was wary of inversions for glaucoma patients. He prefers not to take chances with possible optic nerve damage. A few minutes of elevated pressure day after day, he hypothesized, adds up over the years. Loren Fishman, MD, a longtime Iyengar yoga practitioner, also advises glaucoma patients to weigh the risks of increasing IOP during inversions. In a 2013 New York Times interview, he said, ” I believe headstand and handstand are contraindicated by wide angle and narrow angle glaucoma.”

In a self-administered study, he, then a 67-year-old male without glaucoma, held Salamba Sirsasana and variations for 21 minutes. During this time, his IOP doubled from a 14-15 mmHg baseline to an average of 31-34 mmHg during the next 20 minutes of variations. (Personally I was reassured that IOP stabilizes during a long headstand rather than creeping higher and higher.)

He found a similar 100% increase in Adho Mukha Vrksasana (handstand) to 31-34 mmHg, but much smaller increases in Sarvangasana to 16-22 mmHg and in Halasana to 17-18 mmHg. Viparita Karani was measured at 12-14 mmHg, so IOP was stable and even dropped slightly.

He concluded that Sirsasana causes significant IOP elevation, but that IOP returns to normal once upright. For him–and for those without glaucoma–this temporary rise in pressure seems reasonably safe. There’s no proof otherwise, anyway.

But neither he nor the recent researchers make a recommendation either way for those with glaucoma. Perhaps, if glaucoma is managed with drugs or surgery, it doesn’t preclude inversions (or other poses that increase IOP). For those who don’t know they have glaucoma, however, increasing IOP above their already-high IOP might indeed damage the optic nerve.

What poses could you give up?

Ultimately the decision–whether or not to invert–depends on the individual. How risk tolerant or averse are you? What are you willing to continue or to give up, in the face of health risk?

In terms of yoga asana, how much would you miss Sirsasana and other inversions if you had to give them up? While headstand is fundamental to my practice, there are myriad poses and even I, a creature of habit, could adapt to a no-headstand practice. It would be harder for me to give up Adho Mukha Svanasana. In any case, we must remember that yoga is more than poses–and avoid becoming dependent on any pose or habit or way of living.

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7 thoughts on “Should you go upside-down if you have glaucoma?”

Thank you Luci for this informative post on a topic of interest to teachers and practitioners. I appreciate the range of input (PLOS One, Dr. Loren Fishman, ophthalmologists, your “eye doc”), and your take-homes messages:
(1) proceed in consideration of your individual situation and propensity towards risk, and (2) yoga is more than asana.

Thanks Luci,
Your posts are helpful, thought provoking, relevant and clear. This medically based synopsis of information will increase my understanding of this issue that comes up more frequently as the community of practitioners age… And yes – yoga is so much more than asana!!!

In my years of experience the half inverted poses decrease interocular pressure definitely and I had one student who got her eye doctor to check shoulder stand and for her it also helped to do sarvangasana. Mr Iyengar also used to put on a eye band which created pressure on the eyes.

Hello, when you say ‘half inverted’ what do you mean? Adho mukha vrksasana with feet flat to wall and legs parallel to floor and other like preparatory inverted poses? These strike me as ‘stronger’ and possibly productive of more pressure into head…
Or do you mean like viparita karani or sarvangasna off a chair or ardha halasana with legs resting on a chair? Which seems to create less pressure.
Would love some clarity as I am working with a student who was recently diagnosed with glaucoma. (We have stopped inversions all together- she misses them dreadfully as they benefited her in so many other ways…)
Interested to hear perspectives on how best to work.
With thanks